Low dose Ketamine

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TrueNorthMedic

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Hi all, I was wondering how many places have a protocol for, or use low dose ketamine for pain control? Our current protocols allow use of it to facilitate intubation (1.5 mg/kg) but my ambulance service is currently working on developing a standing order with our medical director to use it in lower doses (0.1-0.3 mg/kg) for pain control. We also have acetaminophen, entonox, morphine, and fentanyl available to us. I'm currently in paramedic school, just learning about it, and from what I've read, ketamine seems like it could work well for pain in certain situations . Just wanting people's experiences and opinions on this. Thanks!
 
Flatlander85 said:
Hi all, I was wondering how many places have a protocol for, or use low dose ketamine for pain control? Our current protocols allow use of it to facilitate intubation (1.5 mg/kg) but my ambulance service is currently working on developing a standing order with our medical director to use it in lower doses (0.1-0.3 mg/kg) for pain control. We also have acetaminophen, entonox, morphine, and fentanyl available to us. I'm currently in paramedic school, just learning about it, and from what I've read, ketamine seems like it could work well for pain in certain situations . Just wanting people's experiences and opinions on this. Thanks!
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I've done it overseas. It hasn't caught on in North America yet. Shame, cause it's legit.
 
We use it here at 0.3mg/kg. Can be give three times, q20. Can also be given IM or IN at 0.5mg/kg repeat once in 20.

It is intended to be used when opioids are ineffective, contraindicated, or otherwise disadvantageous to the patient's condition. In practice this means we try fentanyl for isolated injuries and then move to Ketamine. If the person has a bunch of gnarly injuries we can use it immediately so long as its side-effects (increase in ICP for one) won't cause issue.

It works real well given it's dissassociative properties, and at lower doses it's pretty predictable with a quick onset and about 20 minutes duration. Occasionally you will give someone a bit of a bad time with it, but 0.3mg/kg is not really near the "nightmare" dose. Anecdotally it is not great choice for patients with a PTSD history.
 
Basically what Tigger said. We have it .2-.3mg/kg if fentanyl isn't effective or for whatever reason is a poor choice.
 
Nice! I think our protocol is going to be similar to the ones mentioned; use it if opiates are ineffective or not a good option.
 
We can give Ketamine 0.5 mg/kg to a max of 50 mg, with a second dose of .25 mg/kg every 15-30 minutes PRN at one of the places I work. Works well.

Used to be able to do the same protocol at my main job. But pts. were coming in with some very altered mental states and could not be assessed by the ER Dr. until the med. started to wear off. Ketamine dose was reduced to 0.1 mg/kg. with a max of 10 mg. initial dose. Can be repeated once. Have not been very impressed with the lower results. I think the 0.3 might be a great starting point.
 
.2-.3mg/kg is a good sub-disassociative dose for managing pain. Much higher than that (or even .2-.3 given to rapidly) tends to cause some disassociation and altered LOC, which isn't our goal.
 
Ketamine is used by, as far as I know, all ten ambulance services in Australasia for analgesia.

We've used it for almost ten years with thousands of administrations and no serious problems. I don't know why anybody wouldn't use it, it is absolutely marvelous stuff. I've never seen anybody have a bad time with it and if they do just give them a little bit of midazolam and they'll be right. What I have seen is people screaming in wretched agony despite reasonable doses of morphine (and entonox) suddenly no longer care their pain is there once they have a reasonable amount of ketamine in them.

Here is the text of our ketamine guideline:

Ketamine
• Indicated for very severe pain, particularly musculoskeletal or burn pain not adequately controlled with an opiate.
• Contraindicated if the patient:
a) Is aged less than 1 year or
b) Is unable to obey commands or
c) Has active psychosis or
d) Has current myocardial ischaemia.
• Use with caution if the patient is hypertensive.

• Dosage:
a) 10-50 mg IV every 3-5 minutes for adults or
b) 1 mg/kg (rounded off to nearest 10 kg) for adults IM, IN or oral, up to
a maximum of 100 mg, if IV access cannot be obtained. This may be
repeated once after 10 minutes.
c) For children see the paediatric drug dose tables.
• All patients administered ketamine must be given a firm
recommendation to be transported to an ED by ambulance.
Ketamine notes
• Ketamine is preferably administered in combination with an opiate.
‘Load’ the patient with an opiate until further doses are not providing
additional analgesia. Most adults will need at least 10-20 mg of morphine
or at least 100-200 mcg of fentanyl before ketamine is added.
• The preferred route of administration is IV:
–– For adults dilute 200 mg to a total of 20 ml, or 100 mg to a total of
10 ml. This solution contains 10 mg/ml.
–– For children dilute 100 mg to a total of 10 ml. This solution contains
10 mg/ml.
–– Use a dose at the lower end of the range if the patient is small, frail,
has already received an opiate, or has already received ketamine via
another route.
–– Doses at the upper end of the range should be reserved for very
painful manoeuvres such as extrication of a patient with multiple
limb fractures or straightening of an angulated fracture.
• Other routes of administration:
–– The IM route is preferred over the IN or oral route as IM absorption is more reliable.
–– The IN or oral route should be reserved for the very unusual circumstance in which IM injection is contraindicated.
–– Administer IM and IN ketamine undiluted.
–– For IN administration, administer half of the dose into each nostril using principles within the fentanyl section.

• Side effects:
–– Warn the patient they are likely to feel ‘strange’ following ketamine
administration and ask them to tell you if this occurs.
–– The patient may experience hallucinations with ketamine. Do not
focus on warning the patient about these as such warnings may
increase the likelihood of their occurrence.
–– Hallucinations or ‘awful’ experiences appear more common if small
sub-therapeutic doses of ketamine are administered.
–– Do not treat hallucinations routinely with midazolam. This is
because the combination of midazolam and ketamine is commonly
associated with a reduced level of consciousness, particularly if an
opiate has also been administered.
–– Most hallucinations will settle with a combination of further
administration of ketamine, explanation and time. However,
midazolam in 1-2 mg doses IV may be administered if
the hallucinations are very severe, provided the patient is
physiologically stable.
 
"Special K" - your screen name and avatar finally pay off!
 
I think the disassociative properties are kind of nice. Yes, it's not really possible to have compliant patient for further assessment, but for the most part they're calm, awake, and certainly keeping their own airway reflexes. After 20-30 minutes, it's done. Sometimes this means the doctor's full assessment will be delayed, but this can happen with opioids as well.

Obviously if the patient has a some sort of presume neuro injury we want to be able to assessing them for the duration of our contact and the EDs, but for a nasty extremity fracture I'm ok if they are a bit dissassociated from their injury.
 
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